On the successful treatment of cases of congenital displacement of the hip-joint by complete recumbency with extension for two years

2

ON THE

SUCCESSFUL TREATMENT OF CASES

OF

CONGENITAL DISPLACEMENT

OF

THE HIP-JOINT

By Complete Recumbency with Extension for Two Years.

BY

WILLIAM ADAMS, F.R.C.S.,

Surgeon to the Great Northern Central Hospital, and to the National Hospital for the
Paralysed and Epileptic ; Consulting Surgeon to the National Orthopedic
Hospital ; late President of the Medical Society of London, etc.

Reprinted for the Author from the British Medical Journal. Ftb. 22, ifihu.

PRINTED AT THE OFFICE OF

THE BRITISH MEDICAL ASSOCIATION, 429, STRAND, W.C.

I ON THE SUCCESSFUL TREATMENT OF CASES
OF CONGENITAL DISPLACEMENT OF THE
HIP-JOINT BY COMPLETE RECUMBENCY
WITH EXTENSION FOR TWO YEARS . 1 2

At the meeting of our Association held at Brighton in August,
1886, 1 read a paper in the Surgical Section on The Treatment of
Congenital Displacement of the Hip-joint by long-continued Re-
cumbency and Extension. 3 In that paper, after passing in review
the chief points in the pathology and clinical history of this
affection which are now well established, I brought prominently
before the members the treatment adopted by one of the leading
American surgeons, Dr. Buckminster Brown, of Boston, who had
carried out the recumbency and extension treatment more
thoroughly and for a longer period than had hitherto been done.
Dr. Brown had in 1885 3 published the account of a very successful
case, with photographs taken two years and three months after
the commencement of treatment, which had been continued strictly
for thirteen months. The child then began to walk in a go-cart
for five months longer. To all appearance in this case, one of
double displacement in a girl aged 4 years, there was a complete
restoration of the natural form of the hips, and the lordosis was
also completely removed. The walk was said to be natural, and
the patient’s health not in any way injured.

This success encouraged me to give the treatment a fairer trial
than I had hitherto done. At the time of reading the paper I had
commenced the treatment in two cases, and since then have
applied the same method to four other cases. Two of the six
cases were double, that is, both hip-joints affected, and four single ;
in three of the latter the right hip-joint was affected, and in one
the left hip-joint. In two of the cases, both examples of single
displacement occurring in girls of about 2 years of age at the
commencement of treatment, recumbency with extension has been
carried out to the full period of two years in one, and two years
and seven months in the other case ; and they have been now
some months walking about with a steel support on the affected
limb.

At the present time I am enabled to report that the result of
this treatment appears to be extremely satisfactory, and equally
so in both cases. When these children are examined undressed on

1 Read in the Section of Surgery at the Annual Meeting of the British Medical
Association held at Leeds.

2 Journal. April 23rd, 1887.

* " Double Congenital Displacement of the Hip.” By Buckminster Brown,
M.D. Boston : Cupplee, Upman and Co. 1886.

2

the table there is no apparent inequality in the length of the legs.
Sometimes, by careful measurement, the affected limb seems to be
an eighth, or from that to a quarter, of an inch shorter than the
other, but we cannot always make as much. The ilio-femoral
triangle of the affected limb corresponds pretty closely with that
on the healthy side, so that the head of the femur is now retained
very nearly in its natural situation, and there is no disposition to
any spontaneous alteration. Nor is there any tendency to dis-
placement upwards when gentle manipulation is tried by fixing
the pelvis, and testing by a little movement directed upwards from
the thigh. Of course this has only been tried gently, but the head
of the femur seems to be fairly maintained in its improved posi-
tion ; and the contrast, as compared with the condition of parts
before the commencement of treatment, is very great. All the
movements of the joints are free, and the muscular nutrition has
been well maintained.

The general health has not been in the least interfered with,
and, indeed, in both instances the parents consider that the children
have improved in health. During the whole period of recumbency
these children have been drawn out in a spinal carriage in the open
air, lying down on the movable plane forming part of the exten-
sion couch, the extension acting all the time. This extension
couch I have also used with great advantage in two cases of hip-
joint disease.

At the present time we can only hope that the improvement

f ;ained by the treatment will be permanently maintained, but at
east another six m J be required to test this,

wearing. I will give a further report at the end of that time. The
details of these cases are given below :

Objects of Treatment, and Details of the Method

Adopted.

In reference to the pathological conditions which have now
been shown to exist in these cases, the object of any method of
treatment adopted must be, when the case is undertaken at a
sufficiently early period — say 2 years of age or less — to prevent the
gradual displacement of the head of the femur by the elongation
of the capsular ligament, which takes place when the child begins
to walk and throws the weight of the body upon the limb, or
limbs, in which the congenital malformation of the hip-joint with
imperfect development of the acetabulum exists.

This can only be accomplished by long-continued recumbency
with extension, so adapted that the head of the femur is retained
as nearly as possible in its natural position during a long period
of active growth, say, from a year and a half to two years’ dura-
tion. For this purpose I use the new extension couch, constructed
for me by Mr. Ernst, and described in my paper at the Surgical
Section of our Association at Brighton, in August, 1886, when it
was exhibited at the meeting. Drawings of this couch, given me
by Mr. Ernst, are now shown to the meeting.

At the end of this period the child should be gradually allowed
to walk with a steel support, when one hip-joint only is affected,
somewhat resembling the American hip-joint instrument, which
allows of motion at the hip-joint and still maintains extension,
whilst the weight of the body is removed from the affected limb.
In Sayre’s hip-joint splint the weight of the body is sustained by
the perineal straps attached to the pelvic band, but in the ap-
paratus Mr. Ernst has constructed for me not only are the perineal

after the children

supports they are now

3

bands used, but the tuberosity of the ischium is made to rest upon
the back part of the metal thigh trough, so that every care is
taken to prevent the weight of the body being thrown upon the
affected limb. A raised boot, one inch and a half in thickness, is
worn on the healthy limb, and an iron ring-patten on the affected
limb. To this ring-patten the boot is fastened by short straps,
and the extension is made by a rack-and-pinion movement in the
lever on the leg. As a part of this walking splint I have com-
bined the use of the pelvic belt suggested by Dr. B. Brown, with a
large pad placed just above the great trochanter to assist in pre-
ventingthe head of the femur slipping upwards. With this apparatus
the child may be allowed to walk for six months or a year, when
it may be gradually discontinued, the child at first using crutches
and then one or two sticks. Altogether extension is maintained
for a period of two to three years — I prefer the longer period — and
the head of the femur kept as nearly as possible in its natural
position during the whole time.

When both hip-joints are affected the best form of apparatus to be
used at the commencement of the walking period, that is, in the second
stage of the treatment, is that employed by Dr. B. Brown, a kind
of square go-cart upon four wheels, with a leather strap passing
from before backwards, and buckled upon the cross bars. On the
centre of the strap is a small saddle, on which the child sits at
such a height as to allow only the toes to touch the floor. There
are crutches also attached to the sides of the go-cart to assist in
sustaining the weight of the body, and a webbing belt passes
round the body.

It will thus be evident that the treatment is divided into two
stages.

The principle of the first stage is that of complete recumbency,
with slight extension, and immobility as complete as can be sus-
tained with comfort, continued night and day for a period of
eighteen months to two years. I advise two years if the health
is well maintained — and it has been well maintained in the cases
under treatment. If the case is undertaken at a sufficiently early
period, say, at two years of age or less, the treatment in this stage
is essentially preventive.

The principle of the second stage is that of extension, with
mobility maintained during progression, without the weight of
the body being thrown upon the affected limb or limbs. This can
be accomplished in cases of single displacement by an apparatus
very much resembling the well known American hip-joint instru-
ment, and in cases of double displacement by the go-cart and
saddle used by Dr. B. Brown. This apparatus should be used for
a period of six months to a year — I advise a year. Crutches may
be used at first.

The transition from the first to the second stage should be
made very gradually, the child at first being allowed to walk
with the instrument two or three times a day for a quarter
to half an hour, and then return to the extension couch, which is
also to be used at night during the whole treatment, and pos-
sibly afterwards. During the whole of this stage, and for some
time before it is commenced, massage to the affected limb or
limbs should be practised twice daily for half an hour each time.
It should be applied more especially to the neighbourhood of the
hip-joint and the glutei muscles, but it should also be used to
strengthen the muscles of the thigh and leg in the affected limb
or limbs.

At the end of the second stage, the patient begins to walk in the
ordinary way, without any instrumental assistance, but at the

4

commencement crutches should be used, or the nurse should give the
child assistance by holding it under the arms, so as to prevent the
whole weight of the body being thrown upon the affected limb or

Fig. 1 represents the plan of the extension mechanism. The counter-exten-
sion is taken from the perineum by two perineal straps k k made of
india-rubber tubing; these are cleaner and more adjustable than the
padded form. A chest band I. is attached to keep the child from
moving. Both the chest band and perineal straps are attached to studs
d d on each side of the couch. The extension is made by the thigh
bandage h and gaiter h. This is connected by a cord to the standard r,
which has fixed at the upper part a check attachment known as
Durham’s pulley. The salient point here is the quadrant movement e.
The standard f is fastened at its lower part to a flat sliding piece, which
moves in the quadrant up to the distance of the thumb-screw G;
by this means it is possible to bring the standard to the extreme point
in the dotted line, giving the full abduction of the limb if requisite. As
this quadrant is an arc with the radius emanating from the hip-joint it
is apparent that in abducting the limb no loss or increase in the
extension power takes place. The thumb-screw G is fixed at whatever
position it is desirable to keep the standard.

limbs. The transition from the second stage to walking without
any mechanical assistance must also be made very gradually.
When the case is undertaken at a later period, say about 5

5

years of age, or even up to 8 or 10, when the displacement has
become more confirmed, the same treatment may be carried out,

Fig. 2, showing the method of detachment, will be clearly understood.
The gun metal arches M are regulated so as to permit the tilting and
easy removal ; their shape explains the plan. It is now only necessary
to fasten the “ sliding guides” up to the couch by leather straps, and
the board is complete for outdoor transport. In the cases under treat-
ment the patients live in this position. The couch is fitted with a
horsehair mattress, and at night a blanket and sheet are carefully
placed between the child and the mattress ; this can be best accom-
plished by one person holding the child under the axillae, and extend-
ing gently whilst the perineal and chest straps are unfastened and the
“ bed ” made. In washing it is necessary to place a mackintosh cloth
over the entire mattress. The treatment principally depends on rest
and the maintenance of the limb in an extended position. This is
easily accomplished, for there is no existing contraction, and it is only
when the patient stands that the elongated capsular ligament permits
the rising of the limb and consequent shortening ; the extension force
is therefore very slight, and only sufficient to keep the limb in unison
with the other.

in the hope that the upper and unused portion of the dilated
capsule will spontaneously contract during growth. In uni-

6

lateral displacement, the pelvic tilting and deformity, as well
as the lateral curvature of the spine, will certainly be diminished
to the lowest possible point by recumbency with extension during
active growth, and in a case of double displacement, the pelvic
deformity and lordosis will certainly be diminished.

At a still later period, that is, after 10 years of age, there can-
not be any reasonable hope of much improvement so far as the
articulation is concerned, except in favourable cases, by the sub-
cutaneous operation which I have proposed, in the hope of
obliterating the upper part of the cavity formed by the elongated
capsular ligament. By this means, together with partial recum-
bency and extension, the consecutive deformities may be
diminished during the period of growth, say up to 17 or 18 years
of age.

In cases of unilateral displacement, weight extension at night
and recumbency, or partial recumbency, for four or six hours a
day in a spinal chair will be useful up to 17 or 18 years of age;
and, as a gymnastic exercise, I recommend the use of the trapeze
bar three times a day, the patient wearing a leaden clog, weighing
four pounds, on the foot of the affected limb during the exercise.
By this means the muscles surrounding the hip-joint are brought
into play, whilst the head of the femur is drawn down towards its
natural position by the leaden clog, acting as an extension weight,
attached to the foot. When all hope even of diminishing the
consecutive deformities is given up, it is still desirable that the
patient should avoid long standing, and all walking exercises
should be limited to one hour, and then followed by recumbency
for one hour ; exercise for short periods alternating with rest.

Permanency of the Improvement.

With regard to the permanency of any improvement gained by
long-continued recumbency with extension we must expect the
profession to remain sceptical until sufficient time has elapsed
after the discontinuance of all treatment ; and also until it has
been tried in a sufficient number of cases. I have frequently been
asked : What is to keep the head of the femur in or near to its
normal position when there is no acetabulum ?

I believe the answer will be found in the adapted growth of the
capsular ligament and all the surrounding muscles and fibrous
structures, gradually occurring in the period of two or three
years, during which the head of the femur is retained as nearly as
possible in its natural position.

We know that the displacement of the head of the femur up-
wards, or in whatever direction it may be, is limited by the sur-
rounding muscular and fibrous structures, and that a resting
place is found, not by any new bone thrown out or any attempt at
the formation of a new acetabulum, which would be prevented by
the capsular ligament intervening between the head of the femur
and the surface of the ilium, as the head of the bone never leaves
the capsular ligament; but, still, a circular-flattened depression
is gradually made on the surface of the ilium by the pressure of
the head of the bone. This may be seen in all the specimens,
except the one in St. Thomas’s Museum, in which a little peri-
osteal bone had been thrown out where the head of the femur had
rested. We may therefore reasonably hope that a similar depres-
sion will be made in or near to the natural situation of the ace-
tabulum by the treatment adopted, and this, together with the
adapted growth of the capsular ligament and the surrounding
muscular and fibrous structures, will assist in maintaining the
head of the femur in the improved position in which it has been

7

maintained for two or three years. The unused upper portion of
the capsule, we may also hope, will gradually contract.

Some support of these views may be derived from the following
observation : When the limit of displacement has been reached the
head of the femur becomes much more fixed in some cases than in
others, that is, it cannot be moved downwards by extension ex-
cept to a very limited extent ; and the lower and unused half of
the capsular ligament appears to undergo a process of contraction,
so that it would be incapable of receiving the head of the bone.
The sides of this portion of the cavity may become flattened and
compressed, or approximated, and, without anything approaching
to obliteration, the cavity may be intersected by some bands of
adhesion.

The only specimen in London, so far as I know, in which these
pathological changes can be demonstrated is the one in St.
Thomas’s Hospital Museum, JS T os. 42 and 43, Section D. This speci-
men is figured in the Trans. Path. Soc., vol. xxxviii, 1887, Plates XII
and XIII. The case was evidently one of congenital displacement
of both hip-joints in a girl aged i6 — a dissecting room specimen,
without any history, but it is mentioned that both thighs were
flexed and contracted at the hip-joints, so that movement had
become restricted. One innominate bone, with the upper portion of
the femur, has been completely macerated and put up dry to show
the osseous changes, No. 42, and the other innominate bone, with
the upper portion of the femur, has been partly macerated, with the
capsular ligament dissected and remaining intact and put up as a
wet preparation, No. 43. In the dry preparation, on the dorsum
ilii, near to the upper margin of the sciatic notch, is a flattened,
circular, medallion-like surface, slightly raised, upon which the
head of the femur had undoubtedly rested for a considerable time,
in consequence of impaired mobility from some muscular con-
traction. In the wet preparation the capsular ligament is seen to
be greatly elongated, extending from the upper border of the ob-
turator foramen below to cover the head of the femur above in
its displaced position on the dorsum ilii ; it is also greatly in-
creased in thickness and density. Mr. Sliattock was kind enough,
at my suggestion, to lay open the capsular ligament in front in its
entire length. This exposed the head of the femur, still within
the capsular ligament, at its upper part. In its lower half the
thickened capsular ligament was depressed or flattened so as to
diminish the cavity, which apparently would not have been
capable of receiving the head of the femur, had any attempt bpen
made by extension to draw it towards its natural position. The
inner surfaces of the thickened capsular ligament, although ap-
proximated, were not at any part adherent, but some slender
bands of adhesion passed between these surfaces, intersecting the
cavity

This is the nearest approach to what I think may take place in
the upper half of the capsular ligament when the head of the
femur has been held down by extension for a sufficiently long
period ; or what might be accomplished by the operation I have
8 . u f?f? es t e d, of transfixing the upper half of the cavity by a double
ligature, and then carrying one of the threads subcutaneously
round each segment so as to emerge at the aperture of entrance.
Then each segment could be tied separately, in the hope of oc-
cluding more or less completely the upper portion of the cavitv.
Should more than slight irritation follow the threads could be
cut and removed, and if necessary from excessive effusion with
tension the cavity might be punctured with a small trocar. I
have not yet had the opportunity of performing this operation.

8

For a practical demonstration as to the permanency of the im-
provement obtained by the long-continued recumbency with ex-
tension, carried out by the method I have adopted, sufficient time
has not yet elapsed in my two earliest cases now reported, al-
though the prospect at the present time is extremely favourable.

In Dr. Buckminster Brown’s case, the child was allowed to walk
without any support eighteen months after the commencement of
treatment ; and at the end of two years and three months, when
the published photographs were taken in March, 1885, the im-
provement gained by treatment had been fully maintained. The
result had the appearance of being perfect, and with every pro-
spect of being permanent.

Dr. B. Brown, when residing in Paris during the years 1845 and
1846, had the advantage of seeing three or four of these cases
treated by the late M. Jules Gu6rin, who practised subcutaneous
division of the muscles, followed by extension, with partial though
not complete success, according to the report of the Commission
ssued in 1848. 1 Dr. Brown did not, therefore, adopt the opera-
tion, but relied upon recumbency, with extension.

The late Dr. Camochan, 4 5 who first directed my attention to this
subject in the year 1844, at St. Thomas’s Hospital, also gained his
early knowledge of the affection from the study of Dupuytren’s
unique collection of specimens in Paris, and the observation of the
practice of Guerin and other surgeons. He gives full credit to the
successful result of treatment in some cases of M. Pravaz, 6 of
Lyons, which was confirmed by a report of the Commission of the
Royal Academy of Paris, appointed to examine these cases in the
year 1838. In this report, one case is stated to have remained
cured two years after the reduction.

The best result of the treatment by recumbency with extension
which I have seen, though not carried out to the full extent or in
the manner I have recommended, was in the case of a young gen-
tleman, aged 19, who had been treated in this way, when about 6
years of age, for displacement of the left hip-joint, considered by
the surgeon who attended the case to be the result of infantile
paralysis, for which the same surgeon had previously treated him.

I first saw the case on December 6th, 1872, and pronounced it to be
one of congenital displacement of the hip, an opinion in which Mr.
(now Sir) Prescott Hewett entirely agreed with me. Not a trace
of paralysis existed, nor was there any history of hip-joint disease.
The child had limped from the time it began to walk. Recum-
bency, with a long straight splint and weight extension, had been
carried out for fifteen months, and then very little walking was
allowed, with steel supports, a pelvic belt, and crutches for seven
months. When last seen by me (May 21st, 1883), thepatient being then
19 years of age, there was only one inch and a quarter shortening,
and, with a boot raised one inch and a quarter, the limp in walk-
ing was very slight ; the leg was strong and all the joint move-
ments free. He said he was able to take any amount of exercise.
Only a slight spinal curvature existed in the lumbar region, and
the pelvic tilting was also very slight.

This is the only case I have seen at the completion of growth,
after recumbency with extension has been carried out in child-

4 Rapport adresse ii Monsieur le Delegue du Gouvernement Provisoire sur
les Traitements Orthopediques de M. le Docteur Jules Guerin il l'H6pital des
Enfants pendant les Annees 1843, 1844, et 1845, par one Commission composee
de MM. Blandin, P. Dubois, Jobert, Louis. Raver et Serres. President, M.
Orfila. Paris. 1848.

* A Treatise on Congenital Dislocations of the Head of the Femur. By Dr. John
Murray Carnochan. New York : S. S. and W. Wood, 261, Pearl Street. 1850.

« Iraite des Luxations congenitales du Femur, par le Docteur Pravaz. 1847.

9

hood for congenital displacement of the hip-joint, and the result
must be regarded as extremely satisfactory, -when we considrr
that without treatment the shortening would certainly have been
not less than three inches', and it might have been four or five
inches, which I have seen in several cases of unilateral displace-
ment, the spinal curvature and tilting of the pelvis resulting in a
proportionate degree. This case sufficiently proves the great ad-
vantages of the treatment I have recommended.

It is remarkable that for this valuable illustration we are in-
debted to an error of diagnosis, upon which the treatment was, as
it were, accidentally carried out.

In my own cases, when undertaken at an early age, and the
treatment extended over two or three years, the ultimate result
cannot fail to be good ; but some permanent defect — partly due
to the malformation, and partly to the subsequent changes in the
head and neck of the femur — must remain ; and after the comple-
tion of growth, say at 20 years of age, there will probably be only
about half an inch of shortening, or perhaps from that to one inch
in some cases ; but this result I should consider to be very satis-
factory. Because absolute perfection is not to be reached, and a
new hip-joint made, that is no reason why the consecutive defor-
mities, which invariably result when these cases are left to
Nature, should not be reduced to the minimum point, with a life-
long benefit to the patient.

On the Intermediate or Halfway Treatment.

I have frequently been asked whether anything could be done
to diminish the resulting deformity in these cases when the whole
treatment, according to the programme above laid down, either
cannot be carried out, or is objected to by the parents, either
from a fear of injury to the general health or some other cause.
The answer is that although a halfway treatment can only end
in a halfway result, still by adopting the following rules much
may be done to diminish the consecutive deformity, either in a
case of single or double displacement. When one hip-joint only
is affected

1. Weight extension must be employed during the night, and
part of the day, when the child is reclining on a sofa, say four to
six hours, about two hours each time. The extension apparatus
for this is simple enough, and such as is usually employed in
cases of hip-joint disease.

2. The child may be allowed to walk about in the intervals of
reclining, if old enough to use crutches, and then a raised boot of
one inch and a half must be worn on the sound limb, the foot of
the affected limb not being allowed to touch the ground. The
affected limb will however swing backwards and forwards, and its
own weight will to some extent act as an extending force. This
can be carried out by the poorest class of patients.

Another method of locomotion, when a little expense is not
objected to and more attention can be given, is by means of the
splint or apparatus, which Mr Ernst has constructed for these
cases, somewhat resembling the American hip-joint instrument,
which combines extension with motion, and crutches are avoided,
except perhaps to start with. The child usually gets along very
well with one or two sticks. The raised boot is of course neces-
sary on the sound limb when this apparatus is used, and an iron
ring-patten on the foot of the affected limb, the boot being
attached to the ring by straps, and the extension made by a rack-
and-pinion movement in the side steel. The pelvic belt with pad
placed above the great trochanter should also be used.

10

When both hip-joints are affected weight extension at night-
might bemused ; and recumbency with weight extension, during a
portion of the day, say from four to six hours, taken partly in the
morning and partly in the afternoon. Long standing and long
sitting should be avoided, and the child should walk as little as
possible in the earlier years of life. By these means the con-
secutive deformity will be diminished.

The Two Cases Referred to.

Case i. — Congenital Displacement of Left Hip-joint treated by
Recumbency, with Extension for Two Years and Seven Months . —
Tuesday, December 4th, 1885. Miss S., aged 2 years, was brought
to me by Dr. G. Ransford.

Objective Symptoms. — She walked, leaning on one side, with a
limping gait, dragging the left leg, with the foot everted. This
leg appeared to be short and weak, but well-nourished. I first
tested the muscular power in the various movements at the hip*
knee, and ankle joints, which were all well performed, and I
could find no trace of paralysis. Abduction at the hip-joint was
somewhat limited by tension of the adductor longus. There was
no pain in any movement at the hip-joint, nor any symptom of
hip-joint disease.

Examination of Hip in the Standing Position. — When the child
was standing undressed on the table, i placed a dot of ink exactly
over the anterior superior spinous process, and then, drawing a line
horizontally backwards from this point, it was at once evident that
the top of the great trochanter was on a level with this line, and
that the ilio-femoral triangle was obliterated. On the opposite
side the base of the ilio-femoral triangle measured fully one inch
— that is, the base of the triangle made between the horizontal
line, from the anterior superior spinous process and a line drawn
obliquely downwards from the same spot to the top of the great
trochanter. In this little patient, a fat and well-nourished child,
the top of the great trochanter on the healthy side was not so
easily felt, but this can always be done when the child is stand-
ing on the table if the weight of the body is thrown upon the
heel when the front part of the foot is uplifted, and then, the sur-
geon moving the foot inwards and outwards with one hand, the
top of the trochanter can easily be felt with the other hand as a
movement of horizontal rotation is communicated to it.

This examination conclusively proved that the head of the
femur could not possibly be in the acetabulum if this cavity
existed, and as there were none of the ordinary symptoms of dis-
location, the only conclusion we could arrive at was that the
head of the femur was displaced in consequence of an absence or
malformation of the acetabulum.

Examination of the Hip when Lying Down. — When examined
undressed on the table, the left leg appeared to be nearly one inch
shorter than the right, but by a little extension the length was
easily restored, and the head of the femur evidently moved up
and down through the space of about an inch. With a thumb
on the anterior superior spinous process, and a finger on the top
of the great trochanter, the latter was felt to move up and down
independently of the pelvis, and the base of the ilio-femoral
triangle was easily restored.

This examination proved the deficiency of the acetabulum, and
the diagnosis of the case was clearly established as one of dis-
placement of the femur in consequence of congenital malforma-
tion of the acetabulum.

Dr. Ransford agreed with me in advising the parents that the

11

-child, should undergo the treatment of recumbency, with exten-
sion. which had proved so successful in the case published by Dr.
Buckminster Brown, of Boston, but objections to the long confine-
ment, with restraint, were at first raised.

History. — Dr. Ransford, who attended at the confinement, told
me this was the first child, foot presentation; labour not difficult;
no turning or manipulative interference required ; no peculiarity
noticed at or immediately after tbe birth. The child walked later
than other children, and walked with a limp ; when it began to
walk, the left leg appeared to be weak, so that it seemed to drag,
and the foot was everted.

Wednesday, February 3rd, 1886. Dr. Ransford and myself again
met to examine Miss S., who had been kept off her feet a great
deal, and allowed to walk only for a short time, with a boot
raised half or three-quarters of an inch. We found the hip in
■every respect the same as before. The parents now consented
to the extension treatment being carried out. The only modifica-
tion in Dr. Brown’s treatment which I felt desirous of making was
with regard to the method of carrying out the extension. Dr. B.
Brown’s patient was confined to the bed, that is, outside the bed
the whole time, and extension was made by weights and pulleys.

I wished to have a movable extension plane, resting on a couch,
when the patient was in the bouse, but capable of being carried
about from one room to the other, and also of being placed in a
spinal carriage, so that the child could be drawn into the open
air every day, without any interruption to the extension. This of
course presented many difficulties, but Mr. Ernst undertook it, and
succeeded to perfection in constructing a movable extension plane
and couch, which I have no w used in six cases of congenital displace-
ment and two cases of hip-joint disease requiring extension.

Instead of using the weights and pulleys Mr. Ern3t employed
the check-pulley— sometimes known as Durham’s pulley — and the
cords were fastened to brass standards fastened on the sides of the
movable plane.

On Tuesday, May 18th, 1886, Miss S. began the treatment
regularly, having been on the plane for a fortnight only part of
the day, and no difficulty was experienced in carrying it out. Dr.
Ransford had the case closely under his observation, and I saw
it occasionally.

On Wednesday, June 9th, 1886, we examined the little child, and
the new apparatus seemed to be answering very well, and the
child had already become accustomed to it.

On Wednesday, September 22nd, 1886, Dr. Ransford and myself
examined Miss S. and some improvement had evidently taken
place, as with the slight extension used the left leg nearly corre-
sponded in length with the right, and the ilio-femoral triangle on
the left side more nearly corresponded to that of the right leg.

Friday, October 29th, 1886. At this date there was risk of the
treatment being seriously interfered with, as I received a note
from Dr. Ransford to say that Mrs. S. had taken her child to
Hutton (the well-known bone setter) who said “ tbe hip was dis-
located, that he could reduce it five minutes, and at the end of
two. months the child would be perfectly well and walking.” I
advised that the highest surgical opinion should be taken inde-
pendently of myself, and suggested Mr. T, Bryant, who I knew had
paid much attention to these cases.

Friday, November 5th, 1886. I received a note from Mr. Bryant
to say that he had seen Miss S. in consultation with Dr. Ransford,
and observed : “ The diagnosis is clear, and the benefit derived
from treatment is most encouraging. So much so indeed, that I

12

could not sanction the least deviation from the lines you have laid
down.” '

As a result of this consultation the treatment was resumed, and
on Tuesday, December 14th, 1886, I again saw the case with Dr.
Eansford. We found that when the extension was removed the
shortening of the left leg was scarcely half an inch, and very
slight extension brought the left leg to the same length as the
right, and restored the base of the ilio-femoral triangle. The
parents seemed now to be satisfied that the treatment was likely
to lead to a permanently good result. The child was drawn out
in a spinal carriage once or twice a day, and the health was
perfect.

On March 3rd, 1887, Dr. Ransford and myself examined Miss S.
and found a steady improvement going on. No shortening of the
left leg when slight extension is on, and very little when the ex-
tension is removed. The ilio-femoral triangle is nearly equal on
both sides when extension is removed, and the head of the femur
is evidently becoming more fixed in the improved position. It is
nearly ten months since the commencement of the treatment on
May 18th, 1886, and she will be 4 years old on the 23rd of this
month.

Friday, June 3rd, 1887. I again examined Miss S. with Dr.
Ransford, and we found the measurements and general condition
the same as in the last report.

Friday, September 23rd, 1887. Dr. Ransford and myself
examined Miss S. again and found all the improvement continues,
with some little gain. Both legs the same length with very slight
extension, and hardly any appreciable difference when extension
is removed. The left ilio-femoral triangle nearly equal to the
right. The movements at the hip-joint, tested gently, were all
free. No disposition to spontaneous displacement.

Friday, December 23rd, 1887. I examined Miss S. again with
Dr. Ransford, but there was no alteration to report. The
measurements were the same, and the child in excellent health.

Friday, March 9th, 1888. Dr. Ransford and myself met again,
and on the present occasion, at the request of the family, Dr.
Wharton Hood, whose experience in joint affections has been very
great, was added to the consultation. After carefully examining
the left hip-joint, and comparing it with the opposite hip, and
measuring the length of the legs, in which very little difference —
only about an eighth of an inch — was perceptible, Dr. Hood ex-
pressed himself as much pleased with the result, and said that in
any future case he should adopt the practice. The child’s health
has never been interfered with.

On Wednesday, May 23rd, 1888, I examined Miss S. with Dr.
Ransford again, but there was nothing special to report.

Monday, November 19th, 1888, Dr. Ransford and myself ex-
amined Miss S. again, but found no change. The joint seems to
be improved when a little movement is made, and no disposition
to displacement.

Friday, December 7th, 1888. Dr. Ransford and myself agreed
that Miss S. might now be allowed to begin to walk with a steel
support to the left leg, in principle much resembling the American
hip-joint instrument, but with some special arrangements which
Mr. Ernst suggested, and for this he took the necessary measure-
ments on this day. Mr. Ernst found the shortening of the left leg to
be one-eighth of an inch, and also measuring the base of the ilio-
femoral triangle, whilst I marked the spot, he found that on the
left side to measure one inch and a quarter and on the right side
one inch and three-eighths. Dr. Ransford and myself found the

13

head of the femur could not be displaced upwards by the moderate
degree of force which it was only justifiable to try. When the
great trochanter moved upwards the pelvis moved with it. Alto-
gether the result seemed to be very satisfactory.

Thursday, December 20th, 1888. Miss S. began to walk to-day
with the instrument Mr. Ernst had specially constructed for the
case, and applied it himself. The nurse and mother quickly
understood the details. Dr. Hansford assisted the little child in
her first walk since the treatment was commenced, May 18th, 1880,
just two years and seven months.

Wednesday, February 6th, 1889. Dr. Ransford and myself ex-
amined Miss S.. who has now become well accustomed to walking
about with the instrument and using a pair of crutches. When
examined undressed on the table we could not find that any change
had taken place at the hip-joint, or in the length of the leg. She
walks only for a short time in the morning and afternoon.

Friday, May 10th, 1889. I examined Miss S. again with Dr.
Ransford, and we were unable to find that any change had taken
place. She walks about more freely and with confidence, the
hip- joint moving freely.

Case ii. — Congenital Displacement of Right Hip-joint Treated
by Recumbency with Extension for Two Years. — Friday, October 1st,
1886. Miss D. W., aged 1 year, 9 months, was sent to me by Dr.
Thomas May, Crayford, Kent.

Objective Symptoms.— She walks with a conspicuous limp, and
drops the body to the right side. The right leg appears to be
short and weak. The foot is everted in walking, but can be easily
turned inwards. The movements of the hip-joint are quite free
and painless; but abduction is a little limited, and in this
movement the tendon of the adductor longus becomes rather
prominent and tense. No trace of paralysis in any of the
muscles, either above or below knee. No indication of incipient
hip disease.

Examination of Hip in the Standing Position . — This gave the
same results as in the previous case. The base of the ilio-femoral
triangle on the right side was obliterated, and the top of the great
trochanter was very nearly on a level with the anterior superior
spinous process. On the healthy side the base of the ilio-femoral
triangle was about one inch. The head of the right femur was
evidently displaced in a direction upwards and backwards.

Examination of Hip when Lying Down . — This gave results very
similar to the previous case. The right leg appeared to be about
three quarters of an inch shorter than the left, when the inner
malleoli of both legs were approximated. With the thighs flexed
at a right angle with the body, the child still lying on its back,
this shortening was at once seen to be above the knee-joint. With
a little extension to the right leg, the base of the ilio-femoral
triangle could be restored, and the top of the great trochanter
could be seen and felt to move up and down, proving the deficiency
of the acetabulum. This examination sufficiently established the
diagnosis.

History . — This was a first child, and a breech presentation, but
no turning was employed ; it was proposed, but objected to, and
the labour proceeded without any difficulty, the child being bom
breech first. No instruments were used. She walked later than
other children, not until 1 year and 4 months old, and then with a
limp, which gradually increased and became much worse within
the last three months.

Treatment . — I strongly advised Dr. Buckminster Brown’s treat-
ment by long continued recumbency, with extension, but using

14

the improved plane, as in the previous case, so that the child
could be drawn out daily in a spinal carriage.

On October 29th, 1886, this treatment was commenced, and no>
difficulty was experienced.

December 28th, 1886. I examined Miss W., and there seemed
to be some improvement. With the slight extension on the
plane, the shortening of the right leg was completely removed ;
but when the extension was released, the top of the great tro-
chanter ascended again, but not so far as before treatment was
commenced, hardly more than a quarter of an inch according to
my note. The disposition to evert the foot was at first controlled
by sandbags, and afterwards by a splint contrived by Mr. Ernst*
This little child was constantly under the observation of Dr.
Thomas May, and seen by myself at intervals of about two or
three months. The mother was extremely attentive to all the
details of treatment.

About the end of the first six months, on Tuesday, April 19th,
1887, Dr. May and myself carefully examined the child, with and
without the extension, and the result appeared to be very satis-
factory. When the extension was removed, the legs remained
very nearly the same length, and the head of the femur was evi-
dently becoming more fixed in the improved position ; the great
trochanter did not ascend spontaneously.

On Thursday, December 22nd, 1887, 1 made another careful ex-
amination with the same result and measurements as before. The
general health remains very good. It is now a little over one
year since the treatment was commenced.

On Thursday, May 10th, 1888, Dr. Thomas May and myself ex-
amined our little patient again carefully, only with the result of
the same favourable reports as to the length of the legs, which
were very nearly equal, and the head of the femur becoming more
firmly fixed in the improved position. There had been noticed
some little tendency to elevation of the heel, or rather, I should
say inability to flex the foot beyond the right angle, no doubt
caused by the foot being so long retained in a position with the
toes pointing downwards during the extension, and for this I
directed passive movement of the foot with the right hand, whilst
some extension of the leg was being made with the left hand.
There was nothing further to report.

On Wednesday, October 31st, 1888, as Miss W. has now com-
pleted her two years of recumbency with extension which she
began on October 29th, 1886, it was arranged that she should
begin to walk with a mechanical support, and for this purpose
Mr. Ernst took careful measurements of the right leg, which he
compared with the left. The legs were very nearly of equal
length ; not more than one eighth of an inch shortening on the
right side could be measured. No inclination to spontaneous dis-
placement, or any movement upwards, when a little manipula-
tion to test this was applied. The ilio-femoral triangle was
nearly equal on both sides, the right being about an eighth of an
inch less. The joint movements are all free, and the muscular
power very good. The general health is excellent, in no way
injured by her complete recumbency, with extension, night and
day for two years. During this time she has had a mild attack
of measles, and also the whooping-cough, but the extension was
not materially interfered with.

Monday, November 12th, 1888. Miss W. began to walk to-day
with the instrument which Mr. Ernst has constructed for these
cases, and I have described in the paper. Mr. Ernst applied it,
and, with my assistance, the little girl walked about the room for

15

a short time. This was repeated every day, and she soon got
accustomed to the use of her crutches.

Friday, February 1st, 1889. The little girl can now walk about
alone, using crutches for half an hour in the morning, and the
same in the afternoon. When left to herself on the couch, without
the instrument, there is no disposition to displacement at the hip.

Friday, June 14th, 1889. Has walked without crutches some-
times, during the last three months, holding by the table and
•chairs, but I prefer the use of crutches or two sticks. She lies
down on the extension couch two hours every day, and sleeps on
it, the extension being used. All the measurements are the same,
and there is no disposition to displacement.

Wednesday, August 7th, 1889. She now walks about more freely,
but has been a little restrained lately.

After the last visit to me on June 14th, her mamma took her to
the Zoological Gardens, and the fatigue and excitement were too
much for her, and caused irritability, with some brain excitement
in the evening, which has since recurred in the evening. The
family haying removed to Sevenoaks, Miss W. is now attended by
Dr. Worship. The measurements of the leg and hip-joint remain
'the same, the difference not being more than an eighth of an inch.

v